Tubal Blockage

Tubal blockage or tubal occlusion (the medical term) is the mechanism by which tubal ligation procedures prevent pregnancy. Tubal blockage prevents sperm from being able to reach an egg and also prevents eggs from being able to reach the uterus. When tubal sterilization is performed, tubal blockage is intentional. Tubal blockage also occurs due to disease conditions and results in involuntary infertility. Whether intentional or resulting from disease, tubal blockage can often be corrected with reconstructive tubal surgery.

Causes of Tubal Blockage

Tubal sterilization

Pelvic inflammatory disease (PID). PID is as an inflammatory condition of the fallopian tubes (salpingitis) and may also involve the ovaries (oophoritis), and pelvic peritoneum (peritonitis)

Endometriosis

Congenital abnormalities or malformations of the uterus and fallopian tubes may also result in tubal blockage. In these cases, the blockage is usually at the uterine, or proximal, end of the tube rather than at the fimbrial end as occurs with PID

Treatments for Tubal Blockage There are 2 basic approaches to treat infertility due to tubal blockage:

Tubal Surgery

In Vitro Fertilization (IVF)

Tubal surgery is best performed by gynecologic reproductive surgeons who have specialized training and experience in this area. In Vitro Fertilization (IVF) in essence replaces the functions of the fallopian tube with laboratory and minor surgical procedures that result in fertilization and transfer of fertilized eggs or embryos into the uterine cavity. Since the advent of in vitro fertilization (IVF), reconstructive tubal surgery is becoming a lost skill. IVF is more popular than tubal surgery among reproductive endocrinologists.

Tubal anastomosisâ€“ Tubal anastomosis involves removing the blocked segment of the tube and joining the two remaining open segments. It is also referred to as tubal reanastomosis or tubotubal anastomosis. This is the surgical treatment used when the tubal blockage is between the uterus and the fimbrial end of the tube.

Tubal Implantationâ€“ Tubal implantation is used to correct a proximal tubal occlusion or blockage at the junction of the fallopian tube and uterus. The blocked segment is bypassed by creating a new opening in the uterus and inserting the healthy portion of the fallopian tube into the uterine cavity.

Salpingostomyâ€“ Salpingostomy is creating a new opening in the fallopian tube. This operation, also called neosalpingostomy, is used to correct distal tubal occlusion at or near the fimbrial end of the tube caused by fimbriectomy, PID, or endometriosis.

Benefits and Risks of Tubal Surgery vs. IVF

The primary benefit of tubal surgery to repair tubal blockage is that it is done once. After a tubal blockage is repaired, pregnancy can occur at any time after the surgical procedure. The biggest risk of tubal surgery in an increased rate of tubal pregnancy. IVF has the advantage that it avoids surgery, but it is expensive and requires the use of large doses of hormones to stimulate the ovaries. The use of super-physiologic doses of ovarian stimulating hormones is associated with the risks of ovarian hyper-stimulation and an increased rate of multiple pregnancies. However there is a small risk of tubal pregnancy also in IVF if tubes are open.

Tubal clipping or removal of tubes (salpingectomy) before IVF:

This procedure is undertaken before IVF to prevent the adverse effect of collected tubal fluid flowing into the uterus in presence of gross hydrosalpinx. Severe hydrosalpinx is suspected by ultrasound or hystero-salpingo graphy and confirmed by laparoscopy. If IVF is to be undertaken then it is better to clip the hydrosalpinx laparoscopically so that this collected fluid stops flowing into the uterus where embryos are placed during IVF. Sometimes removal of these diseased tubes (salpingectomy) is also done to improve pregnancy rates. However, removal can compromise ovarian reserve by taking away a part of blood supply of the ovaries and could be difficult in presence of severe pelvic adhesions or frozen pelvis.Poly-cystic Ovarian Syndrome (PCOS) Polycystic ovarian syndrome (PCOS) is a common reproductive disorder associated with irregular menstrual cycles, excessive body hair, acne & oily skin, weight problems and infertility. The syndrome has been thought to be related to high levels of insulin, which is related to the excessive production of male hormone testosterone which results in ovulation disorders. Women with PCOS are also considered prone to other medical problems, such as Type 2 diabetes. Evidence suggests that PCOS can be managed by reducing circulating levels of insulin, thereby restoring normal menstruation & reproductive functions. Doctors should typically encourage patients to lose weight and improve overall nutrition. â€œInsulin sensitizing agentsâ€ should be used only in those women who have diabetes, impaired glucose tolerance, very high insulin levels or are severely obese. In carefully selected patients such agents will reduce glucose & insulin levels, promoting weight loss but they are less successful in regularization of menses or ovulation. Common side effects include gastrointestinal irritation, and the agents are not recommended for patients with kidney, lung, liver or heart disease. Overall, insulin-sensitizing agents have not been linked to birth defects. They also have little risk of multiple pregnancies, compared with ovulation induction drugs. Many drugs are considered to be in an investigational stage. We encourage any women concerned about PCOS and pregnancy to consult our experts and learn more about individual treatment options.

My doctor says I have polycystic ovarian syndrome (PCOS). What does that mean?

This is an endocrine disorder with combination of one or more symptoms. These symptoms include irregular late periods, lack of ovulation, acne, oily skin, excess body hair (face, chest, below navel) and excessive weight gain. Some women have high insulin levels associated with black patches on the skin especially the neck region (acanthosis nigricans).

What happens in PCOS?

Normally every woman has small amount of androgens (male hormones such as testosterone) in her body. In PCOS there is excessive production of androgens by the ovaries, so the amount of free circulating testosterone is high which is responsible for non-ovulation and the other problems.

How common is PCOS?

Polycystic ovarian syndrome affects 5% to 10% of women of childbearing age and is a leading cause of infertility. Polycystic ovaries are also seen in approximately 20% of women normal menstrual cycles.

How can it be diagnosed?

Diagnosis involves a physical examination for features of PCOS along with an ultrasound to check ovaries for polycystic appearance and a blood work up for the same.

What is the cause of excessive or prolonged bleeding?

Lack of ovulation in women in PCOS results in continuous exposure of their uterine lining (endometrium) to estrogen (female hormone). This may cause excessive thickening of the endometrium & heavy irregular bleeding.

Do I need to follow up with my doctor even after I have delivered a child?

Yes, women with PCOS may be at increased risk for developing the adverse consequences of this metabolic syndrome. These could be manifold such as abnormal lipid profile & high blood pressure with increased risk of heart disease, insulin resistance with the risk of developing diabetes early in life and also the risk of abnormal bleeding leading to cancer of the uterus.

It is said that overweight women are more prone for PCOS. What can help them?

Weight loss improves the frequency of ovulation, improves fertility, lowers risk of diabetes & lowers androgen levels in many women & therefore is an important component of therapy. Reduction in fat & sugar intake along with routine exercise like brisk walking for 40 minutes daily will help you to achieve this. What is the treatment of PCOS? Treatment depends upon your goals. Some patients are primarily concerned with fertility, while others are more concerned about menstrual cycle regulation, hirsutism or acne.

What are the treatment options if fertility is the main concern?

If fertility is your immediate goal, ovulation may often be induced with clomiphene citrate, an orally administered fertility medication. Treatment with insulin sensitizers such as metformin, may lead to a better ovulation. Gonadotropins (injectable fertility medications) may be used to induce ovulation if you do not respond to simpler treatment. Laparoscopic ovarian drilling can be done to improve Ovulatory response.

Metformin is a commonly administered drug in PCOS. How does it help?

Metformin is usually administered to PCOS women with high insulin or sugar levels. However, it can also be given to women with normal insulin & normal blood sugar levels. Even though metformin is primarily an antidiabetic drug, but it is administered now through out the world to PCOS women to effectively bring about better egg development without affecting the sugar levels & lowering intra ovarian insulin levels. But the latest consensus is that metformin should be used in a select group of patients (diabetes, impaired glucose tolerance, very high insulin levels & severely obese) and not as a blanket treatment.

If fertility is not the concern, what treatment can be offered to me?

If fertility is not your immediate concern, then hormonal therapy is mandatory to correct your menstrual cycle. Hormones or specific agents (antiandrogens) can be given for the treatment of hirsutism & acne. Life style modification to target ideal body weight by regular exercise & change in food habits can improve the problem of PCOS to a great extent.